Apeceoctomy traditional and new concepts

EDITED BY

THE APICEOCTOMY

DR.AHMED .A.ALRASHEDI.

THE TRADITIONAL ,AND NEW CONCEPTS

OUTLINE

ANATOMYDEFINITION

IDICATIONCONTRAINDICATIONTYPESPROCEDUER

1-ANATOMY

DEFINITION-Endodontic surgery is the management or prevention of

periradicular pathosis by a surgical approach. In general, this

includes abscess drainage, periapical surgery, corrective

surgery, intentional replantation, and root removal.

-The aim of surgical endodontics is to prevent noxious substances from within the root canal causing inflammation in the periodontal ligament and beyond.

-The objective of surgical endodontics is to achieve a satisfactory seal of the root canal and thus prevent noxious substances entering into the adjacent tissues.

-Apiceoctomy,cutting of apex to accessary canal with sealing and removing the necroting cementum which presented

INDICATION

1.Teeth with active periapical inflammation, despite the presence of a satisfactory endodontic therapy.

2 .Teeth with pridectable Failure of RCT because of:

–1 Completely calcified root canal.

–2 Severely curved root canals.

–3 Presence of posts or cores in root canal.

–4 Breakage of small instrument in root canal or the

presence of irretrievable filling material. 23

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3-Procedural errors of RCT due to:

–1 Foreign bodies driven in to periapical tissues.

–2 Perforation of inferior wall of pulpe chamber.

–3 Perforation of root.

–4 Fracture at apical third of tooth.

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2

CONTRAINDICATION1-All conditions that could be considered contraindications for oral surgery concerning the

age of the patient and general health problems ,such as

severe cardiovascular diseases, leukemia, tuberculosis, etc.

2-Teeth with severe resorption of periodontal tissues

(deep periodontal pockets, great bone destruction..).

4-Teeth whose apices have a close relationship with anatomic structures (such as maxillary sinus, mandibular canal, mental foramen, incisive and greater palatine foramen) and if causing injury to these during the surgical procedure is considered probable

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TYPES 1-The Traditional Periapical surgery

2 -Priapical Microsurgery

3-Laser

TRADITIONAL PERIAPICAL SURGERY

3-Apicocurettage

2-Apicoctomy with orthrograde filling

1-Apicoctomy with retrograde filling

SURGICAL PROCEDURE

1-Antibiotic.A preoperative dose of penicillin V potassium (2.0 g) or clindamycin (600 mg) 1 hour before surgery should be considered by the surgeon.

3-Flap Design . There are three principal flap designs for surgical endodontics

1- two-sided2- three-sided

3- semilunar

1-Apicoctomy with retrograde filling

2- Anesthesia

SEMILUNAR FLAP

The semilunar design avoids the gingival margin, and

there is less risk of recession of the gingival tissues

after surgery . However, there are three main disadvantages:

● surgical access to the apical tissues may be

restricted

● it is often difficult to ensure the incision line

ends up resting on bone

● the flap sometimes results in wound

dehiscence

THREE-SIDED (TRAPEZOIDAL)FLAP

The three-sided flap provides excellent access for most surgical endodontic procedures. There should be no undue tension on the flap while it is being retracted.

A modification of the three-sided flap leaves a 3- to 4-mm rim of gingival tissue in situ. This design usually provides satisfactory access to the apical tissues

TWO SIDED FLAP

A relieving incision is made in the oral mucosa

of the buccal sulcus, and the incision is extended

around the gingival margin of the tooth to be treated

.is preferred wherever possible. An advantage of

this type of incision is the ease of repositioning of

the flap after surgery. In most circumstances access

to the apical tissues is satisfactory. If access is not

sufficient, the gingival margin incision can be

extended distally as far as is required, but failing

that, a second relieving incision may be used; the

flap is now a three-sided design.

3-FLAP REFLECTION

Full-thickness flap is raised with sharp elevator in firm contact with bone. Enough tissue is raised to allow access and visibility to apical area.

4-PERIAPICAL EXPOSURE

A sharp probe is pushed through the buccal cortical plate to identify the pathological cavity If there has been loss of buccal bone through pathological resorption

A medium size (5 or 6) round bur is then used to create a window in the buccal bone and expose the apical tissues

5-CURETTAGE OF THE APICAL TISSUES

Curettage is undertaken to remove foreign bodies such as excess root-filling material within the tissues. Any periapical soft tissue is removed with a curved excavator or a Mitchell’s trimmer,

6-APICECTOMY

Approximately one third of apex is removed with tapered bur .The angle of the bur cut relative to the long axis of the tooth is generally 45° for maxillary teeth and greater than 45° for mandibular teeth.

7-RETROGRADE CAVITY PREPARATION

A retrograde cavity approximately 2–3 mm deep is prepared in the cut surface of the apex of the root to accommodate the root-end filling.

A head bur or ultrasonic cutting tip is used to cut retentive axial cavity walls to contain the root-end filling

8-ROOT-END FILLINGA root-end filling is inserted into the retrograde cavity preparation to seal the root surface. Many dental materials have been used, amalgam, gutta percha, gold foil, polycarboxylate cement, Intermediate Restorative Material (IRM®), Super EBA® (ethoxybenzoic acid) cement, composite resin, glass ionomer cement.

Though expensive, mineral trioxide aggregate an ‘ideal’ root-end filling material.

2-Apicoctomy with orthrograde filling

•Which is called the conventional apiceoctomy , it has the same principles of the retrograde one except there is no preparation of periapical area .they use the guttapercha as a orthograde filling material but they found that this firstly expand and then shrink so they not be recommended now day

1-Apicocurettage

•The apicocurettage has the same principles of apiceoctomy with retrograde filling but it is apiceoctomy without resection of the root tip.

It is beter to do apiceoctomy rather than apicocurettage because it will be apiceoctomy at the end.

ENDODONTIC MICROSURGERY

-Endodontic microsurgery, as it is now called, combines the magnification and illumination provided by the microscope with the proper use of new micro instruments

-The advantages of microsurgery include easier identification of root apices , smaller osteotomies and shallower resection. In addition, reveals anatomical details such as isthmuses, canal fins, micro fractures , and lateral canals. Combined with the microscope, the ultrasonic instrument permits conservative, coaxial root-end preparations and precise root-end fillings

-Microsurgery is defined as a surgical procedure on exceptionally small and complex structures with an operating microscope. The microscope enables the surgeon to assess pathological changes more precisely and to remove pathological lesions with far greater precision,thus minimizing tissue damage during the surgery.

NEW CONCEPTS

Semilunar flap, is no longer recommended because of inadequate access and scar formationSecond, the removal of sutures is done within 48 to 72 h, not a week

Third , new suture materials are monofilament, gauge 5 provide rapid healingFourth, the papilla base incision (PBI) has been developed to prevent loss of interdental papilla height with sulcular incisions

Fifth , flap retraction during the surgery is facilitated by making a resting groove in the bone, especially during mandibular posterior surgery, to ensure retraction

The wider base of the flap was an unnecessary procedure, and it creat a lasting scar.

10 x

CLASSIFICATION OF ENDODONTIC MICROSURGICAL CASES

SURGICAL TECHNIQUES

sulcular or mucogingival incisions were chosen

cotton pellets soaked in 0.1% epinephrine and/or ferric sulfate were applied topically as required

The tissue was gently reflected toward the apical area with Molten 2– 4 curette

Osteotomies were performed with an bone cutter in an Impact Air 45 handpiece . A curette and a scaler were used for periradicular curettage. A 3-mm root tip with a 0- to 10-degree bevel angle was sectioned with a 170-tapered fissure bur under copiouswater-spray. Root-end preparation s extending 3 mm into the canal space along the long axis of the root were made with ultrasonic tips driven by ultrasonic unit

Retrograde filling material

Amalgam was the first retrograde filling material used, replaced for the most part by zinc oxide-containing materials such as IRMg and Super EBAg, and now the most ideal material available is MTA. MTA is not only biocompatible but has been shown to have the capability of inducing bone, dentin, and cementum formation Consistent use of MTA resulted in regeneration of periapical tissue including periodontal ligament and cementum.

The Er:YAG laser can make an incision for flap lifting. This laser produces a wet incision (some bleeding) as opposed to a dry incision (no bleeding) produced by current CO2 lasers.

Detoxification of the infected site by lasing directly on the bone – studies have shown that Er:YAG laser energy effects on bone include bacterial reduction.

Ablation of alveolar bone tissue with the Er:YAG laser can be used for remodelling, shaping and ablation of necrotic bone.

Er:Yag lasers have been used for apical surgery.

Root apex resection using the Er:YAG laser in contact mode and preparation of the apex cavity for retrograde

Vaporisation of granulation tissue is efficient with the Er:YAG laser, offering a lower risk of overheating the bone than that posed by the current diode or CO2 lasers.

Er:YAG laser causes no vibration and discomfort while cutting bone and dentin and less damage to soft tissues and bone, as well as less contamination of surgical sites.

1-The Er:YAG system can be used for osteotomies and root resections but the procedure requires more time than a preparation with burs.

2-While the Er:YAG laser may promote faster healing and more comfortable postoperative results according to the manufacturer, the root-end preparation cannot be done with the laser and the procedure still requires microsurgical ultrasonic preparation and filling.

Thank youDr-ahmed.a.alrashedi